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Tuesday, March 11, 2014

Just how screwed up is the US medical system?

Let me count the ways.

Here are three recent stories that highlight what's wrong
with our medical system.

An in-depth report by the Tampa Bay Times found that
hospitals in Florida are charging exorbitant fees for patients arriving at
trauma centers. It led with an account of a patient who spent 40 minutes in a
Fort Pierce trauma center before being transferred to another institution for a
higher level of care. After some diagnostic tests were done, he was on his way.
The tab for the 40 minutes? $32,727.

The Times found that the average charge for a trauma center
activation was over $10,000 and the highest was $33,000. For-profit hospitals
tended to charge the most. These charges were billed regardless of nature of
the injuries, be they minor cuts or abrasions. And as is customary today, the
uninsured were charged the full amounts.

Hospital administrators admitted that the charges were based
on what other hospitals charged and had no relationship to what resources were
used. The fees did not include bills for physician services, which were
separate.

Bloomberg News published an exposé on Mount Sinai Hospital's
alleged practice of scheduling "emergency" cardiac catheterizations.
Patients were said to have been coached to go to the emergency room and say
they were having acute symptoms of heart disease so that insurance or Medicaid
would pay.

One interventional cardiologist was paid $4.8 million by the
hospital in 2012. The article also stated that failure to do enough procedures
might result in a reduction in pay for other cardiologists.

A medical scribe's post on the website KevinMD
stated that he or she was told to indicate that things like smoking cessation
counseling and a full review of systems had been done for patients in an
emergency room regardless of whether they actually had occurred. Checking off
these activities among others raises the documented level of care and results
in increased reimbursement for the hospital and physician.

As I pointed out in a post in December 2012, an electronic
medical record facilitates such activity. This is not to say that fraud could
not have occurred when charts were on paper. It's just easier to do with an
electronic record by checking a box.

There are many other examples of excessive costs and wasted
money, but these are just some that have appeared recently.

A final thought on how screwed up our medical system is.

I googled "Affordable Care Act costs," and a
website called "ObamaCare Facts" came up on the first screen.
Although I am not certain, it seems to be an official government site. It says,
"ObamaCare's cost is estimated at up to net cost of $1.36 trillion dollars
by 2023." [sic] But later, it
admits that the cost could be "between $1 [trillion] and $2.6
trillion."

The following is not my original idea, but despite a
thorough search, I cannot find its source.

The population of the United States is approximately 315
million people. It would have been much cheaper to simply have given every man,
woman, and child $1 million and had them buy their own insurance. This would
easily have covered everyone for the next 20+ years.

CORRECTION 3/12/14:As pointed out by Mike, an astute commenter with math skills, the previous paragraph is misguided and utterly wrong. It did prompt me to rethink the whole thing.People with insurance through work don't need any subsidies. But consider this. If you take the estimated 47 million uninsured and give them just $500/month to help them buy insurance for the next 10 years, the cost would be $2.8 trillion and that's just for the insurance. The cost of administering the program would be extra.

ObamaCare Facts also says that the law will decrease the
growth in health care spending by tens of billions each year, but it's not
clear whether some ACA provisions like establishing Accountable Care
Organizations will really reign in spending. This is not just my opinion.

To me, the ACA seems like a windfall for insurance companies
and hospitals.

Until we do something about controlling costs and
unnecessary procedures like those I mentioned above, the ACA will be a money
pit.

Mike, you are absolutely right. I stand corrected. I should have run this by my daughter, who's got a masters in math. I'm going to leave it as is and see if anyone else notices. So far you're the only one.

The primary purpose of ACA is to decrease the number of Americans without health insurance. Most of the uninsured are poor, so of course the program will increase costs. The best and cheapest way to provide universal coverage is single-payer, but this is currently absolutely impossible politically.

About physician incomes, the standard surveys say that most physician incomes are holding steady, and several specialties have gotten significant increases over the past few years. Is $600K for an average spinal surgeon too little? Too much? Esp. since the efficacy of their procedures is minimal, and there is a huge multiplier-effect to the total costs.

Anon, I agree with everything you said. Insurance companies will never agree to a single-payer system. Their lobby is too powerful. $600K for a spine surgeon? I think you're underestimating. Is that much ok? Maybe.

A single-payer system without cost containment probably wouldn't be great either.

I don't have much of a problem with a spine surgeon making 600K, give or take 100K or so, even I'm not convinced that what they do is in the realm of a critical health issue (relax out there, tongue in cheek). But 4.8 mil for an interventional card? I'm choking. All it takes is one of those to give the general public the idea that we all make that.

I still think the insurance companies played Obama like a fiddle. He brought a knife to a gunfight.

P.S. Scalpel, it's easy to make an arithmetic error when you're dealing with that many zeroes.

The story reeks of sensationalism. "HERE'S A DOCTOR WHO MADE MILLIONS (insert lots of exclamation points). However, that kind of story makes it easy to sell newspapers. and, more importantly, provides a nice scapegoat - one with a face, rather than one with a building. Believe me, I'm not defending this guy, but to me, it seems that this type of story plays a very small role in the big picture. The insurance companies are, as was said, well-positioned, and well lobbied. They will not lose. It's those of us who are the individuals that will.

Shouldn't we (consumers, taxpayers) pay mostly for results, and not just tough, hard work and years of training? After all, we don't pay much to horse buggy craftsmen.

Hate to pick on spine guys again, but 10 years ago the surgical treatment for chronic lower back pain was laminectomy/discectomy. Now the same patients get PLIF, ALIF,XLIF, and prob. other LIF's I have never heard of. The results are about the same: poor. Maybe it's just me, but paying some guy 600k + for results not much, if any, better than physio and rehab seems on the high side.

Same with most elective interventional cardiology, robotic surgery, prostate and breast screening. The papers mostly say they don't do much, yet we pay big big bucks for them. Why?

Physician compensation is only a small part of the problem. The big cost is the associated hospital, lab, equipment, etc. charges.

I don't what the answer is. In situations where per procedure rates are reduced, the physicians just do more of them to get the same income. In other words, attempts to reduce physician compensation in fact increase overall medical costs.

I would think that RVU's would work depending on the specialty. If I get referred to a surgeon for gallbladder, I'd expect to pay him/her by procedure. If I was an internist/FP/peds, it would be by did they talk about non smoking, healthier eating, exercise, lifestyles.

X, thanks but I think you may not completely understand RVUs. The incentives are misplaced. For example, patients with gallstones who have no symptoms do not need cholecystectomies. But the incentive for a surgeon who isn't very busy would be to do the case.

Regarding talking about smoking, it's hard to quantify and easy to cheat. Just click the box that says "Smoking Cessation Counseling."

The health care system is screwed up because everyone tries to run it like a business, even though it should be well known that it is unlike any other business model. We can't control the real quality of doctors and hospitals, since those who are low utilizers of services and technology are not favored by the hospitals, tech companies, pharma ceutical companies etc. Those who overutilize tests and services are viewed as " thorough", despite repeating all the testing done last month or last week, and this iincludes all the auspicious name places that are bandied about. All prices should be standard and not individual , and discounted to the fees that are paid by the insurance companies, and those without insurance should never be charged more then the major insurance cos pay for their constituents. Finally, the hospitals have hired armies of doctors, and told them to "charge" to get their bonuses, and in doing so, fill the coffers of the hospitals by ordering testing that is done and charged by the hospital ! By pushing productivity , the rates of complications seem to be rising, but there is no transparency of that information to the public, and more surgeries and testing seems to be causing even more surgery and testing, and then the ads through the hospitals effuse with self serving accolades of their emplyees. What can possibly be wrong with this paradigm? Just a few of the top wrongs in the system.

Is concierge medicine the way to go? How do these patients fair if they are admitted to the hospital? I read good things about it as far as cost cutting and patient satisfaction but is it only a rosy picture?

I assume that hospitalized concierge patients are followed by their doctor, but I'm not sure. In addition to the up-front cost of retaining the concierge doctor, patients still must have insurance to cover the cost of any hospitalizations or tests.

I was a health care fraud investigator in South Florida for a little over 6 years. It's way worse than anyone thinks. Healthcare waste, fraud and abuse is in the mega billions each year. How many mega billions is that? For your math wizards to ponder. Well expenditures in 2007 were roughly 3 trillion dollars, fraud, defined as willful and with intent is roughly 10% annually, add to that waste and abuse of another 7 to 8%,, and then administrative costs in 20%, and now as Robert KK would say, you are talking some real money. The kicker, is, insurance costs are not the same as robbing a bank. 10K from a bank is 10K, 10K from an insurance is way more because it results in annual increases that continue to expand, (the rule of 7). The ACA now classifies all Medicare, Medicaid and CHIP into one of three categories based on their risks of waste fraud and abuse, limited, moderate or high level, and there are no data bases such as PECOS, and RACs (recovery and audit contracts) and anti RACs (the recovery and audit contractors to review the RACS). However, in reality, the problem is systemic and never fully addressed, and it will get worse with the ACA. This is because many of the outpatient PART B services will now be done in Part A facilities, costing more. In addition, the ACA did nothing about EMTALA, which means you can expect increased billings for emergency room visits, and worse still, Hospitals costs will go up, not down. The ACA will really be the UCA.

I have to wonder what it does to all the students who went into medicine because they thought they were helping people, not getting sucked into a rat race. It doesn't surprise me that the rates of burnout and therefore, mistakes, are not higher than many are figuring.

I think they get nailed by 3rd year or before. By that time you are probably close to $100K in debt unless you're from a medical family, and then the pressure to stay in because of your family heritage is insane.

I also have to wonder about some of the stuff they teach these kids in medical school as to whether or not it is really useful. I've seen a plain old FP a couple years younger than a specialist surgeon figure out diagnoses long before the surgeon. Granted, diagnoses wouldn't be a strong point for a surgeon but you know ...

Sorry Skep. I had a surgeon make the right call the first time (by the time he did something I was close to dropping dead), and then didn't recognize the same thing the second time. However, an FP who had never seen it before checked it out (wonder if he googled it?) and figured it out months before any one else.

One other thing: I don't think most of the kids going into medical school are probably of the 'fall in line' type. There is a lot of don't question us, reverence for the registrar (you call them attendings). Lots of hierarchy and the like. While that can be good for some things, I think the mindset now is quite different in terms of obedience to your higher ups. I think they're also seeing how much their schooling doesn't always prepare them. If I was a caring doctor, here you have a body of evidence based medicine that really can be useful, and no one wants to use it, when it turns out right, then you get caught. If you think that studies showing 25% of the diagnoses or slightly more are wrong, that probably weighs on your brain as you know you are the one that will catch fire for it. Even getting helped out by hospitals and the like, word spreads.

The only way to immune yourself is buttress yourself in ego or bottle it so badly that you end up getting hurt in the end.